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Full text of "United States Navy Medical News Letter Vol. 45 No. 10, 28 May 1965"

NAVMED P-5088 




Vol. 45 



Friday, 28 May 1965 



No. 10 




CONTENTS 



MEDICAL ARTICLES 

A Patient With Abdominal Pain and Fever 

The Waiting Outpatient 

Fatty Acids and Multiple Sclerosis 



FROM THE NOTE BOOK 

Foreign Trainees 

Outstanding Performance of Duty 

Dependents Medical Care 

New Live Oral Vaccine 

Background Information 

An Instrument Designed to Simplify Surgery on a 

Severed or Injured Urethra 

Philosophy and the Fee 

DENTAL SECTION 

Caries Prevalence With High and Low Intake of 
Fluoridated Water 



9 
9 

9 
10 
10 

11 

12 



13 



Effect of Fluoride Dentifrices on Tooth Enamel 
Solubility 

Unsupervised Clinical Trial of Stannous Fluoride 
Dentifrice 

Image of Dentists in New Mexico 

Effects of Calcium — or Phosphorus — Deficient Diets 
on Secondary Cementum and Alevolar Bone of 
Rats 

Personnel and Professional Notes 

PREVENTIVE MEDICINE 



Insect Vector Collection, Ethiopia, 1961 -n 

The Decline of Pellagra in the Southern United 

States 

Malaria Immunology 

Air Pollution 

Safe Holding Temperatures for Cooked Foods 

Warning Against Refrigerators 

Insect Survey— USS Dennis J. Buckley (DDR-808) _ 

Reserve Training for Medical Entomologists 

Know Your World 



13 

14 
14 



14 
15 



15 

17 
18 

19 
19 
20 
20 
21 
21 



United States Navy 
MEDICAL NEWS LETTER 



Vol. 45 



Friday, 28 May 1965 



No. 10 



Rear Admiral Robert B. Brown MC USN 
Surgeon General 

Rear Admiral R. O. Canada MC USN 
Deputy Surgeon General 

Captain F. R. Petiprin MSC USN, Editor 

William A. Kline, Managing Editor 

Contributing Editors 

Aviation Medicine Captain C. E. Wilbur MC USN 

Dental Section Captain C. A. Ostrom DC USN 

Occupational Medicine CDR N. E. Rosenwinkel MC USN 

Preventive Medicine Captain J. W. Millar MC USN 

Radiation Medicine Captain J. H. Schulte MC USN 

Reserve Section Captain C. Cummings MC USNR 

Submarine Medicine Captain J. H. Schulte MC USN 



Policy 
The U.S. Navy Medical News Letter is basically an 
official Medical Department publication inviting the 
attention of officers of the Medical Department of the 
Regular Navy and Naval Reserve to timely up-to-date 
items of official and professional interest relative to 
medicine, dentistry, and allied sciences. The amount 
of information used is only that necessary to inform 
adequately officers of the Medical Department of the 
existence and source of such information. The items 
used are neither intended to be, nor are they, sus- 



ceptible to use by any officer as a substitute for any 
item or article in its original form. All readers of the 
News Letter are urged to obtain the original of those 
items of particular interest to the individual. 

Change of Address 

Please forward changes of address for the News Letter 
to: Commanding Officer, U.S. Naval Medical School, 
National Naval Medical Center, Bethesda, Maryland 
20014, giving full name, rank, corps, and old and new 
addresses. 



FRONT COVER: Aerial view of the U.S. Naval Hospital, Oakland, California. Located in the East Oak- 
land foothills on the former 208 acre site of the Oak Knoll Golf and Country Club. 

The hospital was commissioned on 1 July 1942 with 6 ward buildings and 204 beds ready for occupancy. 

Construction kept pace with the developments in the Pacific, and in 1 945 the hospital was caring for more 
than 6,000 patients and had a military and civilian staff of approximately 3,000. 

An important step in the development of Oak Knoll came in 1950 when the Navy's West Coast Centers 
for care of amputee patients and those with neuropsychiatric problems were moved here from Mare Island 
when that hospital was reduced to dispensary status. 

It serves as a general hospital and also provides specialized treatment in thoracic, cardiovascular, and 
plastic surgery, neurosurgery, surgery for deafness and for repair of the cornea, malignant diseases, neuro- 
logical and neuropsychiatric problems. — Editor. 

U.S. NAVY MEDICAL NEWS LETTER 



MEDICAL ARTICLES 

A PATIENT WITH ABDOMINAL PAIN AND FEVER 

Mayo Clinic Proceedings 40(3): 260-269, March 1965. 



Resume of Case 

A 30-year-old white man entered the hospital on 
June 14, 1963, complaining of nausea, vomiting, 
fever, and abdominal pain of 3 weeks' duration. 

One month earlier he had had a chill and aching 
pain had developed in the right lower quadrant of 
the abdomen; there were intermittent sharp exacer- 
bations of the pain. After observation for 1 week, 
an appendectomy was performed, but the appendix 
was found to be normal. Limited exploration of the 
abdomen revealed no abnormalties. 

The patient felt well for 4 days. Then the pain 
in the right lower part of the abdomen recurred 
and was accompanied by nausea and vomiting. The 
pain spread to the back, and discomfort occurred 
in the anterior part of the chest during inspiration. 
Fever and night sweats developed. The patient be- 
came weak and anorectic; he lost 20 pounds. There 
had been no known exposure to farm animals, che- 
micals, or infectious diseases. 

The blood pressure measured 120 mm. Hg systo- 
lic and 70 mm. diastolic; the pulse, 94 beats per 
minute; and the temperature, 100° F. The patient 
appeared to be acutely ill. Breath sounds were de- 
creased over the right lung interiorly, and there was 
increased dullness to percussion in the same area. 
A recent appendectomy scar was evident on a 
slightly distended abdomen. No mass was delineated 
There was marked tenderness with muscle guarding 
over the entire right side of the abdomen. The ten- 
derness extended into the right flank, but no rebound 
tenderness was elicited. Flexion and extension of the 
thigh exaggerated the pain. Tenderness was noted 
along the right side of the rectum. No rectal mass 
was felt. All back motion was limited by pain in 
the right flank. 

Urinalysis showed a specific gravity of 1.011, acid 



Conference arranged by Richard E. Weeks, MD, Section of 
Medicine, Philip E, Bernatz, MD, Section of Surgery, and Jack L. 
Titus, MD, Section of Experimental and Anatomic Pathology. 



reaction, no albumin or sugar, grade 2 erythrocytosis 
and grade 1 pyuria. Blood hemoglobin measured 
13.6 gm. per 100 ml. Red blood cells numbered 
4,580,000 per cubic millimeter and white blood cells 
8100 — lymphocytes 11 per cent, monocytes 7, neu- 
trophils 81, and eosinophils 1. A urine culture and 
two blood cultures gave negative results. There was 
no reaction to tuberculin. The erythrocyte sedimen- 
tation rate (Westergren) was 84 mm. in 1 hour, 
and the prothrombin time was 25 seconds. Blood sug- 
ar measured 100 mg. per 100 ml.; blood urea, 32. Se- 
rum bilirubin measured 1.1 mg. per 100 ml., indirect, 
and 0, direct. Serum amylase measured 160 units; 
serum glutamic oxalacetic transaminase (SGOT), 
3.66 micormoles/hr./ml. The value for thymol tur- 
bidity was 1 unit. Cephalin-cholesterol flocculation 
was negative. Electrophoretic values for serum pro- 
teins were as follows: albumin 3.45 gm. per 100 
ml,, alpha-1 globulin 0.47 gm., alpha-2 globulin 0.94 
gm., beta globulin 0.78 gm., gamma globulin 0.86 
gm., and total protein 6.50 gm. Agglutination to 
Salmonella typhosa H antigen measured 1 to 160; 
to the O antigen, 0; to S. paratyphi (para A), 1 
to 80; to S. schottmuelleri (para B), 0; and to Bru- 
cella, 0. A roentgenogram of the chest revealed ele- 
vation of the right hemidiaphragm, prominence of 
the right hilus, and discoid atelectasis of the left 
lower lobe of the lung. Limited motion of the eleva- 
ted right hemidiaphragm was evident on fluoroscopy. 
Hepatic density was enlarged to twice the normal 
area. No fluid levels were apparent. An excretory 
urogram showed the right kidney to be higher than 
the left, with evidence of extrapelvic pressure; the 
left side appeared to be normal. A roentgenogram 
of the lumbar spine showed six lumbar vertebrae 
with sacralization of L-6 and a narrow lumbosacral 
space. 

Fever to 101° F. persisted each day. Analgesics 
were required for pain, although the need was 
thought to decrease slightly during the 5 days of 



U.S. NAVY MEDICAL NEWS LETTER 



observation. Diffuse abdominal tenderness persisted 
but was more marked on the right and in the epigas- 
trium. No mass was felt. On June 19, 1963, an 
operation was performed. 

Discussion of Case 

Hugh R. Butt, M.D., Section of Medicine, Modera- 
tor: Dr. Beahrs will discuss the case. 

Oliver H. Beahrs, M. D., Section of Surgery, Dis- 
cusser: This 30-year-old white man had been com- 
plaining of nausea, vomiting, fever, and abdominal 
pain for 3 weeks when he entered the hospital in 
June of 1963. One month earlier he had developed 
an aching pain in the right lower quadrant with in- 
termittent sharp exacerbation. After observation for 
1 week an appendectomy was performed, but the ap- 
pendix was found to be normal. Limited exploration 
was carried out, I would assume through a small 
right lower-quadrant incision, and the findings were 
essentially negative. I would like to ask if any further 
information was available regarding the extent of 
this limited exploration of the abdomen. 

Martin A. Adson, M.D., Section of Surgery: We 
did call the surgeon who did the exploration. He 
commented on the limited exposure obtainable from 
the incision but said he had been able to reach up 
to the region of the gallbladder and liver. He thought 
that these structures felt somewhat abnormal, but 
he could define nothing definite. . . 

Dr. Beahrs: Could you tell me exactly where the 
incision was for this exploration? 

Dr. Adson: I believe this was either the usual 
McBurney or Rockey-Davis incision in the right 
lower quadrant. 

Dr. Beahrs: And not excessively low down? 
Dr. Adson: Correct. 

Dr. Beahrs. As the information is presented here, 
the examination was entirely negative. I would like 
to know the patient's residence, if this information 
is available. 

Dr. Butt: South Dakota. 

Dr. Beahrs. And do we know whether he has 
traveled outside of this country at all? And also 
what his occupation was? I understand there has 
been no exposure to farm animals, chemicals, or 
any infection. I would like to know if he has traveled. 
Dr. Butt: He was an electronics technician and 
according to the note I see on the history had not 
traveled, at least not abroad. I never saw this patient. 



Dr. Beahrs: Did he have a history of alcoholism 
or of using any medication to excess? 

Dr. Butt: No. 

Dr. Beahrs: Did he have a previous history of 
jaundice or heptatitis or of any liver disease? 

Dr. Butt: No. 

Dr. Beahrs: He was a white person. Was there 
any evidence of hemochromatosis or was there any 
skin discoloration that would make one suspicious 
of any underlying or systemic disease? 

Dr. Butt: No. 

Dr. Beahrs: Had he been injured in the recent 
past? Had he had an automobile accident or a farm 
accident? 

Dr. Butt: No. 

Dr. Beahrs: He had lost 20 pounds — what was 
his weight? 

Dr. Butt: He was 6 feet, 1 inch tall and weighed 
173 pounds. 

Dr. Beahrs: From his history he had apparently 
been running a fever of 100° F. for about a month 
before his admittance to the hospital, and he ap- 
peared to be acutely ill. Although his abdomen was 
slightly distended, I would assume that any mass 
present in the abdomen would have been felt but 
I see that none was felt. There was no rebound 
tenderness. I assume that there was not a proctosco- 
pic examination; on rectal examination, however, 
there was tenderness on the right side of the rectum. 
Assuming that this is correct, I also assume that 
there was no fullness in the right inguinal region 
that would lead one to think that there was an iliop- 
soas or retroperitonal abscess. 

As far as the laboratory findings are concerned, 
the urinalysis was essentially normal and satisfactory 
except for the red blood cells in the urine. His pain 
was in the right portion of the abdomen. Did it 
radiate into the right groin, or into the right lower 
extremity, or was there any urinary urgency or fre- 
quency? And, thinking of a kidney stone, was there 
a determination of blood calcium? 

Dr. Butt: There was no radiation of the pain, 
and blood calcium was not measured. 

Dr. Beahrs: That red blood cells were in the urine 
may not be important. The excretory urogram shows 
evidence of extrapelvic pressure on the kidney with- 
out evidence of calcification. The white blood count 
was only 8100, and this seems to me to be rather 
important in view of the patient's history; the differ- 
ential was essentially normal and it is especially in- 
teresting that the eosinophils numbered only 1 per 
cent. The cultures of urine and blood were negative. 



U.S. NAVY MEDICAL NEWS LETTER 



The sedimentation rate was 84 ram.; this is high 
and would lead me to think that certainly there was 
an inflammatory process or maybe a malignant tu- 
mor. The value for blood sugar was slightly in- 
creased, which is probably not important. The value 
of 32 mg. per 100 ml. for blood urea would lead me 
further to feel that kidney function was probably 
satisfactory, even though the excretory urogram 
showed a defect on the right. The serum bilirubin 
and amylase were within normal limits. The SGOT 
value of 3.66 micromoles/hr./ml. is a little high, 
assuming that the upper limits of normal would be 
1.43. The prothrombin time at 25 seconds is abnor- 
mal (normal, 17 to 19 seconds). This might indicate 
some dysfunction of the liver. Cephalin flocculation 
was negative, which is no help. The serum proteins 
were pretty much within the normal limits in the 
various fractions. But yet I am a little concerned 
regarding the serum albumin being 3,45 on a basis 
that this is a young 30-year-old man otherwise healthy 
up until a few days before the appendectomy and 
up to 3 to 4 weeks before his appearance in Roches- 
ter. The total proteins, likewise, were within normal 
limits, but maybe the values were a little lower than 
one might expect. The values for alpha- 1 and al- 
pha-2 globulins may have been a little high, while 
those for the other two fractions were essentially 
normal. I would like to have Dr. Stauffer give me 
his opinion regarding the serum proteins, as to 
whether or not they are normal or abnormal. I 
would assume that they are slightly abnormal for 
this man. 

Maurice H. Stauffer, M. D., Section of Medicine: 
I would like to say that the serum proteins have 
only two mentionable points. First of all, as was 
commented by Dr. Beahrs, the value for albumin 
is at the lowest limit of normal and for this man 
probably was abnormal. In consideration of the oth- 
er values, that for alpha-2 globulin (0.94 gm.) is 
slightly increased over the upper limit of normal 
which is about 0.8. Whenever you see this, you 
should think of either an inflammatory or a malig- 
nant process. Very commonly various tumors or in- 
flammatory diseases will give a little "bump" in the 
alpha-2-globulin portion of the electrophoretic pat- 
tern. The fact that the value for gamma globulin 
was normal makes one tend to lean away from the 
diagnosis of cirrhosis or parenchymatous hepatic 
disease. 

Dr. Beahrs: Thank you. The agglutination test 
is of no help. The roentgenogram of the chest re- 
vealed the right hemidiaphragm to be elevated. Dr. 
Pugh, would you comment on the roentgenograms? 



David G. Pugh, M. D., Section of Diagnostic 
Roentgenology: The diaphragm is elevated, the 
lungs are normal, and there is no appreciable pleural 
reaction in the right base. The next roentgenogram 
shows elevation of the diaphragm and nothing much 
else. Again there is no evidence of pleural reaction. 
There is no fluid that we can see in the thorax. 
There is a little prominence of the hilar shadows, 
and I think we might assume that this is probably 
just prominence of the shadows of the pulmonary 
vessels because of the elevation of the diaphragm. 
This film taken of the patient in the supine position 
does not show any great displacement of the stom- 
ach. There is a large soft-tissue mass in the right 
side of the abdomen, shown by the density that is 
seen and also by the fact that there are no loops 
of bowel visible in the right upper part of the abdo- 
men. The lower border of this shadow would indi- 
cate that it represents liver, but whether the entire 
mass is due to an enlarged liver or whether the liver 
has been pushed downward and the diaphragm 
pushed upward by some other mass is not evident. 
Next is a left lateral decubitus film obviously taken 
to see if any air-fluid levels could be demonstrated 
in the right upper quadrant. This is the proper and 
best procedure to check for subphrenic abscess be- 
cause almost any upper abdominal operation will 
often leave the diaphragm elevated and splinted, and 
this does not mean very much. A large liver will 
elevate the diaphragm and make it so that it does 
not move much. Therefore, lack of movement of the 
diaphragm does not help in questions of subphren- 
ic abscess. The procedure of choice in suspected 
cases of subphrenic abscess is the obtaining of both 
right and left lateral decubitus films. The left lateral 
decubitus film, which puts the right side up, will 
demonstrate an air-fluid level in the right upper quad- 
rant if air is present. The right lateral decubitus 
film, which we don't have here, would help show 
if there were any pleural effusion on the right side. 
There is no evidence in this case of pleural effusion 
on the right, nor is there any evidence of an air-fluid 
level indicating a subphrenic abscess. An upright 
film taken for the same reason as the lateral decu- 
bitus film showed no fluid either free in the abdomen 
or encapsulated in an abscess in the upper right 
quadrant. We have the excretory urogram which 
showed good filling in 5 minutes, and the urologist 
interpreted this as showing extrinsic pressure on the 
right kidney. 

Dr. Beahrs: From these x-rays, I gained several 
points of information; one is, and I think Dr. Pugh 
agrees, that there is no pleural effusion or pleural 



U.S. NAVY MEDICAL NEWS LETTER 



reaction. This would certainly make me discount, 
somewhat, the presence of a subdiaphragmatic abs- 
cess. The second is that there is no fluid level to 
be seen, which likewise would make me discount 
the possibility of an abscess in the subdiaphragmatic 
or subhepatic areas. Also, the x-rays reveal a large 
right abdominal mass which extends well down into 
the right lower quadrant. The presence of this mass, 
even though it probably primarily involves the liver, 
could very easily be responsible for pain in the right 
lower part of the abdomen; for the pain also was 
present in the right flank and right side of the back. 
I assume that the process involved the liver or that 
the mass was the liver. I would discount subphrenic 
and subhepatic abscesses on the basis that there was 
no obvious history or demonstration of an etiologic 
agent for these. Now these factors do not eliminate 
the possibility of an abscess, but they do decrease 
the chance. There was no history of duodenal ulcer 
with perforation, of recent enteritis, or of injury, 
hematoma, or infection that might be the basis for 
an abscess. The appendix was found to be normal, 
and the symptoms preceded the appendectomy. No 
fluid levels were evident on the roentgenograms, and 
there was no pleural effusion. The liver was en- 
larged, or at least there was a very large right abdom- 
inal mass, and I would think that, if this were due 
to a subphrenic or subhepatic abscess, fluid levels 
should have been present, or at least some etiology 
of the hepatic or subphrenic or subhepatic abscess 
should have been apparent. Certainly a white count 
of 8100 with the differential as it was would make 
me discount the presence of an inflammatory proc- 
ess, or at least an acute inflammatory process. The 
blood cultures were negative, which would lead me to 
believe that this was a noninflammatory process, but 
they certainly do not rule out inflammation. The 
sedimentation rate was high; this could go with a 
subphrenic or subhepatic abscess or a malignant 
tumor. I suspect that an intrahepatic process was 
present. Results of the various liver functions tests 
suggest that at least serious liver dysfunction was not 
present, but I think there was some cellular disease 
of the liver because the tests were not entirely nor- 
mal, the sedimentation rate was increased, and the 
prothrombin time was prolonged. A chronic liver 
process, such as a pyrogenic abscess and hydatid ab- 
scess are two other considerations, but I think for 
various reasons I would discount these. I believe 
liver tumefaction is present because of the liver size, 
the evidence of cellular disease of the liver, the eleva- 
tion of the diaphragm without evidence of a sub- 
phrenic abscess, and the presence of pressure on the 



kidney. The pain is compatible with this diagnosis. 
There is no known primary source, from the history 
or examination, which could be responsible for a 
tumor of the liver in this patient. 

Discusser's Diagnosis 

Dr. Beahrs: I would conclude that a primary tu- 
mor of the liver is the basis of this man's trouble. 
Since the man was acutely ill and had lost weight, 
the tumor would more likely be malignant than 
benign. 

Clinical Diagnosis 

Dr. Butt: Thank you, Dr. Beahrs. The clinical 
diagnosis, just handed to me, was subphrenic abscess. 

Are there any other suggested diagnoses from the 
audience? Dr. Stauffer, what do you think of the 
chance of this being a primary tumor of the kidney 
with metastasis to the liver? 

Dr. Stauffer: I think that it is possible. Frankly 
I don't know; but there are some things here that 
might make one consider a primary tumor of the 
kidney, either with or without hepatic metastasis: 
the red cells in the urine and a few other items, 
such as the abnormal prothrombin time, which we 
have seen with hypernephroma. This mass as seen 
on the roentgenograms does look as if it is a con- 
fluent mass entirely comprised of liver, but perhaps 
there might be a mass below the liver. I would say 
that hypernephroma is one possibility to be 
considered. 

Dr. Butt: Any other suggestions for a diagnosis? 

Physician: Retroperitoneal fibrosis. 

Dr. Butt: Dr. Dahlin will discuss the pathologic 
findings. 

Pathologic Findings 

David C. Dahlin, M. D., Section of Surgical 
Pathology: I received a specimen of the liver from 
Dr. Adson. It showed an obvious adenocarcinoma 
involving the liver. It was composed of cords of 
large clear cells which resembled hepatic parenchy- 
mal cells. Some of the cells contained a little brown 
pigment, presumably bile. Hence, I made the diag- 
nosis of malignant hepatoma. 

Large adenocarcinomatous masses of indetermi- 
nate origin in the right upper quadrant, when com- 
posed of large cells, bring up differential considera- 
tions which include hepatoma, renal-cell carcinoma, 
and adenocarcinoma of the adrenal glands. In this 



U.S. NAVY MEDICAL NEWS LETTER 



case, the brown pigment seemed to label the tumor 
as a bile-producing hepatic carcinoma. 

At necrospy, which was performed elsewhere, 
numerous dark-colored metastases were found 
throughout the body, including the lungs, heart, and 
kidneys. Hepatomas can be dark brown if they pro- 
duce a lot of bile, or if they contain a lot of hemosid- 
erin from an old hemorrhage into them. One of the 
lymph nodal metastases found at necropsy showed 
cells growing in cords as is characteristic of hepato- 
ma. One of the pulmonary metastases contained 
abundant intrecellular dark brown pigment. Dr. 
Shorter and Mrs. Mary Noser did special studies 
on this pigmented material and found that the stain- 
ing characteristics supported its being melanin rather 
than bile or iron. Accordingly I must reluctantly 
accept the diagnosis of malignant melanoma in this 
case. 

Assuming the stains to be valid and that this was 
malignant melanoma, it must have come from else- 
where in the body, since malignant melanomas 
practically never begin in the liver. It might have 
come from some "blemish" in the skin which was 
removed years ago; the primary lesion might have 
been in some location undisclosed at necropsy such 
as above the hair line in the skin or from some 
mucous membrane. The liver in this case was not 
cirrhotic, but it did show evidence of extramedullary 
hematopoiesis suggesting extensive replacement of 
the bone marrow by metastasis. 

Why should one have a problem in differentiating 
melanoma from hepatoma? Both may contain dark 
brown pigment. Furthermore, melanoma is notorious 
for its capacity to stimulate other neoplasms. Melano- 
mas may have an organoid pattern simulating adeno- 
carcinoma; sometimes their cells spindle and mimic 
sarcoma; in other cases, marked pleomorphism is 
seen. 

Dr. Butt: Any questions from the audience? Dr. 
Adson, you operated on the patient. Would you like 
to comment? 

Dr. Adson: Preoperatively, we considered infec- 
tion to be the most likely basis for this patient's 
problem. The patient's departure from normal health 
was abrupt, and the history of onset of difficulty 
prior to exploration and appendectomy elsewhere 
was compatible with a complication of duodenal ulcer 
or cholecystic disease. Most impressive on physical 
examination preoperatively were the signs generally 
indicative of an inflammatory process. He exhibited 
a daily spiking temperature and appeared toxic. 
There was tenderness over the entire abdomen with 



marked tenderness and muscle guarding and rigidity 
on the right. The roentgenographic studies demons- 
trated again today were obviously of great value and, 
in retrospect, we were remiss in being influenced 
to little by these studies after once having formulated 
our initial diagnostic impression. 

The operative approach used proved to be satis- 
factory. The incision was placed well out in the later- 
al part of the abdomen, where extraperitoneal drain- 
age could be accomplished if necessary. There being 
no evidence of abscess, it was a simple matter to 
open the peritoneum which overlay the nodular liver. 
The incision gave satisfactory exposure for biopsy 
and exploration which left no question about the 
presence of an unresectable lesion. 

Dr. Beahrs: Dr. Dahlin, I assume that a search 
was made for a primary melanoma and that none 
was found. 

Dr. Dahlin: I don't know how extensively we 
searched, but we did search for a primary lesion. 

Dr. Beahrs: Well, would the presence or absence 
of a primary skin lesion influence your pathologic 
diagnosis at all? 

Dr. Dahlin: As I say, I am relying heavily on 
the special stains that Dr. Shorter provided in this 
case, and I think we have to assume that this is 
melanoma. 

Dr. Stauffer: I had melanoma on my list of diag- 
noses, and I would like to say just a word about 
this. This clinical syndrome with metastatic melan- 
oma has been described in the literature within the 
last year or two. Metastatic melanoma often gives 
systemic symptoms that are somewhat out of propor- 
tion compared with other tumors, especially with 
fever, chills, and often abdominal pain. This pattern 
occasionally may mimic a common duct stone, and 
I have been impressed with the febrile nature of 
metastatic melanoma in the liver. Examination of 
the urine for melanin in this case probably would 
have made the correct diagnosis. 

Dr. Dahlin: I think another comment is in order 
regarding the problem of finding metastatic melan- 
oma when it is unsuspected. This happens several 
times a year here, probably most often in neurosur- 
gery. Sometimes, in such instances, when we talk 
to the patient's relatives they recall his having had 
a black cutaneous lesion removed, maybe several 
years before. Sometimes the patient has had a "blem- 
ish" burned off with some kind of cautery. 

Dr. Butt: Are there any other questions? 

Physician: Would you comment on the incidence 
of melanoma in men of this age? 



U.S. NAVY MEDICAL NEWS LETTER 



Dr. Dahlin: Well, I am sure that, overall, melan- 
oma is much more common than hepatoma, espe- 
cially in the noncirrhotic liver in a man of this age. 



But given what was found at necropsy in this case, 
and no history of primary melanoma, then I think 
hepatoma would have the edge statistically. 



THE WAITING OUTPATIENT 



The Lancet, London, December 26, 1964, 



The Ministry of Health has just sent to hospital 
authorities an account 1 of conditions in some outpa- 
tient departments in this country. It is concerned 
mainly with two aspects of delay in seeing outpa- 
tients — the interval between date of referral by a 
family doctor and date of appointment, and the time 
that elapses between a patient's arrival by appoint- 
ment in the outpatient department and his entry into 
the consulting-room. 

Waiting in an oupatient department is sometimes 
unavoidable: a clinician may be called to an emer- 
gency in the wards or to an urgent case arriving 
without appointment. Such things are understan- 
dable and are accepted by waiting patients if the 
position is explained to them sympathetically by a 
nurse or receptionist. More often, long waits in the 
outpatient department are the result of imperfect ad- 
ministration. Too many patients may be booked for 
the first half of the clinic, and waiting-time can often 
be reduced by spacing appointments more widely. 
(This point was made in another context by an O 
& M report- on the ambulance service, which noted 
that at a number of hospitals 80% or more of ap- 
pointments were made for the first hour of a ses- 
sion.) Periodically, clinics should be timed to see 
whether any adjustment is needed in the spacing of 
appointments or elsewhere in the organization of the 
clinic. An appointment system in itself is not e- 
nough: it needs checking from time to time. There 
is still the feeling in some hospitals that punctuality 
in keeping an appointment with an outpatient is not 
a matter of the first importance. More efficient ad- 
ministrative methods and their intelligent application 
can do much to reduce the inconvenience of long 
waiting-times — with little or no expenditure of 
money. 

Much more serious, however, is the other de- 
lay — the lag between referral and appointment. A 
delay of two weeks is not unreasonable, but in six 
out of the eight hospitals studied in the Ministry 
survey delays of four to six weeks were usual in some 
specialties, and occasionally they extended to eight, 
ten, or even twelve weeks. To this delay must be 
added any time that elapses before X-ray and labora- 



tory investigations are completed. In at least two 
hospitals where patients had waited some weeks for 
an appointment, there were delays of up to a further 
eight weeks before a barium meal could be done, so 
the final diagnosis took up to sixteen weeks from the 
date of referral. Delays of this order had come to be 
accepted as a permanent feature of the outpatient 
services of the hospitals concerned. We refuse to 
believe that a wait of eight weeks for a barium meal 
cannot be reduced — even in X-ray departments that 
are inadequately staffed, as many regrettably are. 
The first (and perhaps the most important) step 
is to recognize that delays of this length are not 
"normal". 

Inordinate delay in getting a consultant opinion 
makes nonsense of the value of a consultative outpa- 
tient service. Although urgent cases may always be 
seen promptly, a non-urgent condition may well de- 
teriorate during a few weeks' delay; and the patient 
is kept in a state of anxiety, return to work may 
be delayed, and the family doctor may be worried 
and doubtful about how to handle the case in the 
meantime. "Having regard to the difficulties created 
for the patient, general practitioner and hospital 
alike, the inability of any hospital to give patients an 
early appointment to see a specialist is to be regarded 
as a major deficiency of the out-patient services." 1 

The trouble is widespread. The Ministry's study 
confirms previous inquiries, 3 many unpublished in- 
vestigations by regional hospital boards, the exper- 
ience of general practitioners up and down the coun- 
try, and the laments of countless dispirited patients 
and relatives. It is unfair to lay too much blame 
on the hospitals or regional boards. They know only 
too well that a long waiting-time for a consultant 
opinion does nothing to enhance a hospital's reputa- 
tion for efficiency, and no hospital willingly writes 
to general practitioners in its area advising them (as 
has been done) to send their patients elsewhere. 
Since 1 948 the number of patients referred to hospi- 
tal for specialist opinion has increased enormously 
and the present position stems from the knowledge 
of the public and of general practitioners of what 



U.S. NAVY MEDICAL NEWS LETTER 



they have a right to expect under our National 
Health Service. Though staffing and building in ho- 
spitals have also greatly increased, demand has out- 
stripped this progress by miles. 

A long wait for a consultant opinion is nearly 
always the product of two factors : relative or abso- 
lute lack of consultants; and too little working space. 
It is useless to appoint more consultants if there 
is no place for them to work in the outpatient 
department. In many hospitals, outpatient consult- 
ing-rooms are fully occupied throughout the week, 
and various buildings (some quite unsuitable) have 
been pressed into use for additional sessions. The 
building of new outpatient departments of modern 
design is the answer to this part of the problem, 
but under the present building plan progress will 
not be rapid. Meanwhile, temporary extensions (as 
suggested in the Ministry's study) can be costly, not 
so much for the shell of additional buildings as for 
the service installations needed in an outpatient 
department — and most hospitals are already short 
of money for their current needs. If working space 
is available and the delay is due only to shortage 
of consultant staff, additional appointments can be 
made — if money is available. Consultants, however, 
naturally expect to have beds as well as outpatient 
sessions, and this can lead to difficulty. 

Absence of medical staff through sickness, holi- 
days, or other reasons is named in the Ministry 
report as the largest cause of delay in giving patients 
a consultant appointment. Here is probably the most 
intractable problem of all. Under their terms of ap- 
pointment, consultants are expected to cover one 
another's absences, but owing to other hospital com- 
mitments this is very seldom possible. It is one thing 
to supervise the inpatient work of an absent col- 
league, since ward visits can be fitted in at odd times: 
it is quite another to free oneself for a whole session 
at a fixed time to see his outpatients. Locums are 
suggested, but anyone who has tried will know that 
consultant locums are very hard to find, because 
they are almost entirely limited to recently retired 
men. So far as they are available, however, they 
should certainly be used. 

The suggestions in the Ministry's circular seem 
likely to do no more than touch the hard core of 
the disability. But the great value of the document 
is that it asks hospital authorities to look once more 
at the situation and to give their recommendations, 
hospital by hospital. The one word which is nowhere 
mentioned, however, is "money". If the Minister 
wills the end (and Mr. Robinson spoke forcefully 



on this matter only the other day 4 ), he must also 
will the means. 

FATTY ACIDS AND 
MULTIPLE SCLEROSIS 

The suggestions that high-fat diets 5 and diets rela- 
tively deficient in unsaturated long-chain fatty acids 6 
might predispose to multiple sclerosis in susceptible 
individuals were put forward several years ago. Alli- 
son 7 has studied differences in the prevalence of mul- 
tiple sclerosis in certain communities in relation. to 
various geographical features and diet; and his find- 
ings were not inconsistent with the idea that a low 
intake of unsaturated acids might be one of many 
possible aetiological factors. Until recently, however, 
there has been very little direct biochemical investi- 
gation of the fatty-acid composition of the lipids 
of nervous tissue or body-fluids in this disease, with 
a view to determining whether any abnormalities are 
present which might fit in with the dietary theories 
quoted above. 

In 1963 Baker et al. s reported that lecithin ex- 
tracted from macroscopically normal white matter 
from brains of 9 patients with multiple sclerosis con- 
tained relatively more palmitic acid (saturated) and 
less palmitoleic and arachidonic acids (unsaturated) 
than did the corresponding lipid fractions from the 
brains of 6 patients in whom there was no evidence 
of neurological disease. Gerstl et al.,° on the other 
hand, found slightly reduced levels of both saturated 
and unsaturated acids in the total lipid extracts of 
white matter from one case of multiple sclerosis. 
Baker and his co-workers suggested that the shift 
towards greater saturation of the fatty acids in brain 
lecithin in multiple sclerosis, which their findings in- 
dicated, could reflect either some local abnormality 
in lecithin metabolism in the brain itself or possibly 
some alteration in the proportions of saturated and 
unsaturated fatty acids reaching the brain. These ob- 
servations clearly raise a number of questions con- 
cerning fatty-acid metabolism in the brain and the 
blood (and also perhaps in other tissues such as 
liver and intestine) which might secondarily affect 
the fatty-acid composition of the blood-lipids. 

In a recent extensive study Baker et al. 10 mea- 
sured the proportions of different fatty acids (both 
free and esterified) in the total lipids of serum 
from 47 patients with multiple sclerosis. The results 
were compared with those from a control group 
composed of 20 healthy subjects, and 18 "neurologi- 
cal" controls who were carefully matched with the 
multiple-sclerosis patients as regards physical char- 
acteristics and diet, and who came from the same 



U.S. NAVY MEDICAL NEWS LETTER 



wards in the same hospitals, though they had other 
neurological diseases. The multiple-sclerosis pa- 
tients were subdivided into four groups of increasing 
severity, based mainly on the criterion of degree 
of clinical deterioration, if any, in the preceding 
month. In general, the four groups of patients so 
defined also showed increasingly severe physical 
handicap; the neurological controls were therefore 
similarly graded by severity of handicap. The results 
showed a highly significant reduction in serum-lino- 
leic-acid in the multiple-sclerosis group as a whole 
compared with the controls. Furthermore, it was 
clearly shown that in multiple sclerosis the percen- 
tage of linoleic acid falls progressively with increas- 
ing evidence of recent clinical deterioration. No sig- 
nificant fall related to degree of physical disability 
was discernible, however, in the control subjects. 

Discussing these interesting findings, the authors 
point out that it is improbable that they simply 
reflect dietary differences or the effects of decreased 
mobility, and as yet we can do more than speculate 
about their precise significance in relation to multiple 
sclerosis. These results do not, however, agree with 
those of earlier workers. Gerstl et al. 11 found normal 
levels of dienoic acids, such as linoleic acid, in the 
serum-Iipids of 1 1 cases of "active" multiple sclero- 
sis, although the levels in 9 "inactive" cases were 
abnormally high; and Tuna et al.'- reported that 
the percentage of palmitic acid was reduced, while 
that of linoleic acid was normal, in 7 clinically active 
cases. 

These reports underline the urgent need for fur- 
ther work on lipid metabolism in man in relation to 
the demyelinating group of diseases. For example, 
it will be interesting to know more about the distri- 
bution of linoleic acid between the various lipid frac- 
tions of human serum in multiple sclerosis (as al- 
ready proposed"), since it is known that in normal 
subjects the major proportion is present as cholester- 
ol linoleate. In this connection it is relevant to con- 
sider the work of Glomset 13 and others who have 
studied the enzymic transfer of fatty acids from le- 
cithin to cholesterol in human plasma; most of the 
acids so transferred are unsaturated. There may well 
be other transferases catalysing fatty-acid exchange 
between some of the other types of complex lipids 



in blood. Another question which arises, therefore, 
is whether any abnormality in these enzymes is de- 
monstrable in multiple sclerosis. 

Although much is known about lipid metabolism 
in the nervous system of some animal species, 14 com- 
paratively few studies have yet been made of the 
metabolism of lipids in human nervous tissue, espe- 
cially in relation to disease. Enzymes capable of de- 
grading phospholipids (phospholipases A and B) 
have been shown to be present in human brain, lr ' 1S , 
and recently an enzyme system capable of re-es- 
terifying partially degraded phospholipids (lysophos- 
phatides) with fatty acids has also been demonstrat- 
ed in postmortem human brain 17 ; in rat brain this 
type of enzyme, like that originally described in rat 
liver, 1 " is most active in the presence of unsaturated 
acids. It has been suggested that this enzyme system 
may function in a cyclical manner, together with 
the phospholipid-degrading enzymes, and thus me- 
diate a continuous "turnover" of one of the fatty- 
acid moieties of some of the complex lipids in nerv- 
ous tissue. If this were so it could constitute one 
mechanism by which the fatty-acid pattern of brain 
lipids might be altered in disease, either because of a 
change in the fatty-acid pattern of the blood reach- 
ing the brain, or conceivably because of some abnor- 
mality in the enzymes themselves. Whether or not 
these various observations and speculations can even- 
tually be integrated and shown to have relevance to 
the pathogenesis of human demyelinating disease are 
stimulating questions for future research. — The 
Lancet, London, December 26, 1964. 
References 

1. A Study of Some Management Problems in the Out-patient 
Department. Enclosure to HM (64) 102. 

2. See Lancet, Nov. 7, 1964, p. 1003. 

3. ibid. 1963, ii, 1151. 

4. ibid. Nov. 21, 1964, p. 1131. 

5. Swank, R. L. Amer J Med Sci, 1950, 220, 421. 

6. Sinclair, H. M. Lancet, 1956, i, 381. 

7. Allison, R. S. Proc R Soc Med, 1963, 56, 71. 

8. Baker, R. W. R,, Thompson, R. H. S., Zilkha, K. J. Lancet, 
1963, i, 26. 

9. Gerstl, B., Tavaststjerna, M. G., Hayman, R, B., Smith, J. K., 
Eng, L. F. J Neurochem. 1963, 10, 889. 

10. Baker, R. W. R., Thompson, R. H. S., Zilkha, K. J. J Neurol 

Neurosurg Psychiat, 1964, 27, 408. 
It. Gerstl, B„ Davis, W. E., Smith, J. K., Ramorino, P. M., Orth, 

D. L. Amer J Clin Path, 1957, 27, 315. 

12. Tuna, N., Logothetis, J., Kamtnereck, R. Neurology, Minneap. 
1963, 13, 381. 

13. Glomset, J. A. Biochem Biophys Acta, 1962, 65, 128. 

14. Rossiter, R. J. in Neurochemistry (edited by K. A. C. Elliott, 
I. H. Page, and J. H. Quastel); p. 870, Springfield, III., 1962. 

15. Gallai-Hatchard, J., Magee, W, L., Thompson, R. H. S., Webster, 
G. R. J Neurochem, 1962, 9, 545. 

16. Marples, E. A., Thompson, R. H. S. Biochem J, 1960, 74, 123. 

17. Webster, G. R. Biochem Biophys Acta (in the press). 

18. Lands, W. E. M. J Biol Chem, 1960, 235, 2233, 



5TAFF QUITS SMOKING AT SCHOOL 

Faculty of a Cambridge, Md., school have given 
up smoking on school grounds as an example to 
their students. E. T. Myers, principal of the 800- 
pupil St. Clair Elementary School, says the vote of 
the 31 faculty members to give up tobacco on cam- 



pus was unanimous and voluntary. The move came 
after a discussion session in which teachers and 
other school personnel explored what images pupils 
held of them.— Public Health Reports 80(3) :258, 
March 1965. 



8 



U.S. NAVY MEDICAL NEWS LETTER 



FROM THE NOTE BOOK 



FOREIGN TRAINEES 

Six doctors from foreign navies who are currently 
assigned to Oakland Naval Hospital for training in 
their specialties had a broader view of the United 
States when they traveled to Washington and New 
York on a "foreign officer informational objectives 
visit" arranged for them through the office of the 
Chief of Naval Operations. 

They left San Francisco Monday, April 26, for 
New York for visits to the United Nations, the 
World's Fair, and other points of interest in the na- 
tion's largest city. Two days later they went to Wash- 
ington, D.C. for a four-day visit which included ses- 
sions of Congress, tours of the White House, the 
Pentagon, the monuments, and the National Insti- 
tute of Health, Bethesda, Md. 

In Washington they were joined by six foreign 
officers from the U. S. Naval Submarine Medical 
Center, New London, Conn. 

In the Oak Knoll group are CDR Chang Yong- 
taek and LT Paek Un-sang of the Korean Navy; 
LCDR Sha Chen-hua and LCDR Yang Toa-sheng 
and LT Wu Ke-shiu, Chinese Navy, and LT Stavros 
S. Vlavianos, Greek Navy. 

CDR Raymond H. Watt en of the hospital staff 
will serve as escort officer for the travelers. — Public 
Information Office, U. S. Naval Hospital, Oakland, 
Calif. 

OUTSTANDING PERFORMANCE 
OF DUTY 

To: LT Robert M. Beazley, MC USNR, 
636290/2105 

During the period August 1964 through February 
1965 I observed your performance of duty as pros- 
pective Officer-In-Charge and Officer-In-Charge of 
South Pole Station. It was extremely gratifying to 
me to see you assume these responsibilities with 
calm assurance. With so short an exposure to the 
Navy prior to assuming your present duties it is 
obvious that your outstanding performance as Offi- 
cer-In-Charge is based on exceptional natural leader- 
ship qualities. 

By effectively organizing the work to be done and 
above all by your own energetic and enthusiastic 
example you have developed and organized your 



men into an effective team. Throughout the summer 
season working long hours under difficult conditions 
you and your men handled your part of the station 
resupply and refueling effectively and with dispatch. 

As I leave the Task Force, I commend you for 
your outstanding performance in a difficult and try- 
ing assignment. Your leadership, initiative and en- 
thusiasm are in the best traditions of the Navy. 

Commander, Antarctic Support Activities DET 
ALFA is directed to append a copy of this message 
to your next fitness report. 

S/J. R. Reedy, RADM USN 

DEPENDENTS MEDICAL CARE 

One of the most important sections of the Depend- 
ents' Medical Care Act authorizes care of eligible 
dependents in civilian facilities, under regulations 
prescribed by the Secretary of Defense after consul- 
tation with the Secretary of Health, Education, and 
Welfare. Generally speaking, authorized civilian care 
may be obtained at Government expense only when 
a dependent is residing apart from the sponsor; or 
when it has been determined that required care can- 
not be provided by a uniformed services facility 
located within reasonable distance of the patient's 
residence, in which event a DD Form 1251 (Non- 
availability Statement — Dependents Medical Care 
Program) normally is required. (NOTE: These brief 
paragraphs are not intended to be complete; see 
SECNAV INSTRUCTION 6320.8B for detailed 
policies and procedures.) 

The Navy's share of the cost of care of eligible 
Navy and Marine Corps dependents by civilian 
sources is paid by the Bureau of Medicine and Sur- 
gery from funds appropriated by the Congress. 
These costs have increased since the effective date 
of the Dependents' Medical Care Act until they now 
represent one of the largest single items in BuMed's 
annual budget. In terms of appropriated funds only 
(ignoring reimbursements earned for services ren- 
dered in naval hospitals), these medicare costs are 
now greater than the funds appropriated for opera- 
tion of all naval hospitals. 

Historically, it has been extremely difficult to 
match available funds to these increasing costs. As 



U.S. NAVY MEDICAL NEWS LETTER 



9 



a result, it has been necessary for Navy Comptroller 
to transfer funds not only within BuMed's availabil- 
ity but also from other bureaus and offices of the 
Navy Department funded under the same appropria- 
tion — "Operation and Maintenance, Navy." This re- 
programming of funds is not desirable; it means that 
the purposes for which funds originally were budg- 
eted — worthy purposes or the funds would not have 
been requested and could not have been justified 
cannot be accomplished. 

What is BuMed doing about this undesirable fi- 
nancial situation? In attempting to make maximum 
use of existing naval medical facilities, the Surgeon 
General has asked the Commanding Officer of each 
naval hospital to provide care for an average of two 
additional active duty dependent patients a day. He 
has brought the problem to the attention of the 
Chiefs of other bureaus and offices, and has asked 
them to provide similar guidance to activities under 
their command. Finally, the Surgeon General has 
informed Commandants of Naval Districts, the Chief 
of Naval Air Training, and Commanding Generals 
of major Marine Corps commands of the magnitude 
of our problem and of the necessity for attaining 
optimum utilizaton of the existing capability of naval 
medical facilities. In brief, all possible action has 
been taken to effect some diversion of civilian medi- 
care hospitalization to naval medical facilities. 

This article is presented in the U. S. Navy Medical 
News Letter to acquaint all medical officers with 
the seriousness of the problem, and to request their 
continued cooperation in its solution. That continued 
cooperation not only will be sincerely appreciated, 
but will help to ensure that budgeted funds will be 
available to carry out the purposes and programs 
originally planned. — Prepared by: A. E. Calahan, 
Assistant Comp. for Budgeting, BUMED. 

NEW LIVE ORAL VACCINE 

A successful field trial of a new live oral vaccine 
against adenovirus type 4, the main cause of severe 
acute respiratory disease in military recruits, was an- 
nounced by Surgeon General Luther L. Terry, Pub- 
lic Health Service, Department of Health, Educa- 
tion, and Welfare, and RADM Robert B. Brown, 
Surgeon General, Department of the Navy. 

Taken in the form of a capsule, the vaccine was 
100 percent effective in preventing acute respiratory 
illness in 135 Marine recruit volunteers at a training 
camp where adenovirus 4 was epidemic. By contrast, 
almost 25 per cent of a control group of 132 who 
had been fed a placebo (a capsule not containing 



vaccine) were hospitalized with severe adenovirus 
respiratory disease during the same epidemic. 

The vaccine represents a new concept in immuni- 
zation against respiratory disease. A special coating 
on the capsule prevents the vaccine from being re- 
leased until it reaches the intestinal tract. Thus the 
live vaccine bypasses the normal site of adenovirus 
infection, the respiratory tract. In the intestinal tract 
the vaccine causes a symptom-free infection that sti- 
mulates the production of protective antibodies. 

The vaccine is the product of a comprehensive 
effort of the Vaccine Development Program of the 
National Institute of Allergy and Infectious Diseases. 
The idea was bom in the Institute's Laboratory of 
Infectious Diseases. The Institute is one of the nine 
components of the National Institutes of Health, the 
principal medical research center of the Public 
Health Service. 

Wyeth Laboratories, Inc., manufactures the cap- 
sule under a contract with the National Institute of 
Allergy and Infectious Diseases. Institute scientists, 
in cooperation with staff members of the District 
of Columbia Department of Corrections, tested the 
capsule for safety in volunteers at the Lorton Refor- 
matory in Lorton, Virginia. 

The field trial at the Parris Island and Camp Le- 
jeune Training Centers was conducted by physicians 
of the National Institute of Allergy and Infectious 
Diseases, the Parris Island Marine Recruit Training 
Center, the Naval Medical Field Research Labora- 
tory at Camp Lejeune, and the Epidemic Intelligence 
Service of the Communicable Disease Center of the 
Public Health Service. 

Acute respiratory disease is the leading cause of 
hospitalization and treatment at outpatient clinics 
among recruits in all branches of the Armed Forces. 
Ten percent of these illnesses result in pneumonia. 
Yearly adenovirus epidemics at military training 
camps throughout the country in fall, winter, and 
spring rank second only to accidents as a cause of 
lost manpower. Loss of training time and increased 
medical care during one adenovirus type 4 epidemic 
at a single military recruit installation were estimated 
to have cost $10 million. USDHEW, Bethesda, 
Md. 

BACKGROUND INFORMATION 

The search for virus particles in the blood of 
leukemia patients has been a logical application of 
a discovery made three years ago by Drs. Dalton 
and Moloney that causative viruses could be recov- 
ered from the blood of leukemic laboratory rats. 



10 



U.S. NAVY MEDICAL NEWS LETTER 



And the application of the immunofluorescent tech- 
nique to the detection of possible leukemia viral an- 
tigen in human tissues is the outgrowth of work 
on a rodent leukemia virus completed by Drs. Fink 
and Malmgren only last year. 

By spinning at high speeds in a centrifuge the 
blood of laboratory rats infected with the Moloney 
virus, Drs. Dalton and Moloney obtained virtually 
pure virus in the form of pellets. When very thin 
slices of the pellets were examined with the electron 
microscope, which magnifies 100,000 times or more, 
the virus particles were seen as distinctive spherical 
doughnut-like bodies. 

By the use of a special staining technique worked 
out in collaboration with Dr. Francoise Haguenau 
of the College of France, Paris, Drs. Dalton and 
Moloney found about a year later that electron mi- 
crographs showed another form of the rodent leuke- 
mia virus with a characteristic shape, a six-sided 
head and a tail. The tadpole-shaped particle is now 
regarded as the typical form of the last stage in 
the development of the virus as seen in negatively 
stained material. 

The fluorescent antibody technique in which 
known antibodies tagged with fluorescent material 
adhere to specific antigens in animal tissue has been 
used for some time for the detection of viruses in 
tissues. However, the rodent leukemia viruses are 
only very weakly antigenic and adaptation of this 
technique to the study of viral antigen in the tissues 
of mice and rats infected with the Rauscher leuke- 
mia virus was the result of months of effort on the 
part of NCI's Drs. Fink and Malmgren. 

Their work began with preparation of a pellet 
using the Dalton-Moloney method. This pellet from 
the plasma of Rauscher-virus-infected mice was re- 
suspended in liquid and injected into full-grown rab- 
bits. Careful testing of the rabbits' serum at stated 
intervals revealed when antibodies to mouse plasma 
protein had been formed. This indicated to the in- 
vestigators that the rabbits had reacted to the mouse 
protein accompanying the virus and, presumably, 
antibodies to the virus itself might also have been 
formed. Serums prepared in this manner did, indeed, 
show a strong neutralizing capacity for the virus 
when mixed with it before injection into mice. 

To prepare the fluorescent antibody, the rabbit 
serums were pooled, heated to inactivate them, then 
absorbed with normal mouse plasma until no anti- 
body reactive with the normal plasma portion of 
the pellet remained. The protein that was left was 
tagged with fluorescein isothiocyanate. 



Imprints of tissues from leukemic mice were 
treated with the fluorescent antibody and examined 
under ultraviolet light for the yellow-green fluoresc- 
ence characteristic of a specific reaction. Flou- 
rescence occurred in the nucleus and in the cyto- 
plasm of leukemic cells, indicating the presence of 
Rauscher virus antigens. Cells from normal mice 
and rats and from animals infected with other 
viruses did not react with the Rauscher antiserum. 

Investigators at Baylor University have been using 
a technique of pseudoreplication in the virus studies 
they have reported. Basically, this is a physical 
method for the identification and quantitation of 
viruses which is being used by cancer investigators 
as a stop-gap measure awaiting the successful tissue 
culture propagation of suspect human leukemia viral 
agents. 

By staining virus particles with potassium phos- 
photungstate, scientists are able to enhance the vis- 
ual contrast so necessary for successful electron mi- 
croscopy and yet maintain structural detail. This 
latter factor makes it possible for electron microscop- 
ists actually to count particles of a size thought 
to be characteristic of the virus under study. 

Development of all these techniques has sparked 
numerous studies at the National Cancer Institute 
and other institutions across the country. Lacking 
other clues, investigators examining the blood of hu- 
man leukemia patients are looking for particles that 
resemble and behave in a manner similar to those 
obtained from the blood of leukemic laboratory ani- 
mals. The specimens that appear to contain such 
particles are being tested in non-human primates and 
in tissue culture in the hope of obtaining information 
as to whether the particles are cancer-causing 
viruses. 

AN INSTRUMENT DESIGNED TO SIMPLIFY 

SURGERY ON A SEVERED OR INJURED 

URETHRA 

Dr. Robert H. Peters, Jr., MD, 1221 Wyoming 
Avenue, Forty Fort, Pa. 

Dr. Robert H. Peters, Jr., MD, has furnished the 
following directions for use of his newly developed 
instrument : 

After suprapubic opening is made into the blad- 
der, the large female sound is introduced into the 
prostatic urethra. It is usually best to then have the 
assistant hold the top or handle of the female sound 
down toward the umbilicus. The smaller male sound, 
with its attached guide is then introduced into the 
urethra of the penis. Both sounds should be well 



U.S. NAVY MEDICAL NEWS LETTER 



11 



lubricated. After the introduction of the sounds, they 
are assembled at the guides. The sounds are then 
brought together gently keeping the penis stretched 
on the male sound. A slight rocking motion can 
be used until they meet completely at the guides. 
This helps to assure the meeting of the male and 
female sounds in the urethra without trapping tissue 
between the two. The tips of both sounds can be 
palpated at the perineum. 

While holding them in joined position, they are 
rotated until the small or male sound is brought 
into the bladder: an indwelling catheter is then su- 
tured to its end. This catheter can then be drawn 
back through the entire urethra. The catheter is kept 
in place until proper healing takes place. 

Note: The guides are constructed from a solid 
piece of stainless steel rather than joined pieces to 
further simplify construction. 

Naval hospitals may obtain further information 
about the instrument direct from Dr. Peters, if 
desired. 

PHILOSOPHY AND THE FEE 

In the wake of the Saskatchewan crisis of 1962, 
and in recognition of the social changes surrounding 
them, the Canadian Medical Association two years 
ago set up a committee "to consider the whole 
situation of the profession vis-a-vis Government and 
recommend fundamental principles of policy which 
they deem important to the future of the practice 
of medicine". Entitled the Philosophy of Medical 
Care, this committee's report appears as a supple- 
ment to the Canadian Medical Association Journal. 1 

Having examined several existing systems of med- 
ical care, the committee are particularly interested 
in the Australian arrangements by which the patient 
can reclaim part of what he pays the doctor. 2 They 
are attracted to this system because the patient has 
to pay part of the cost of the service directly. Total 
prepayment, whether by Government or by an insur- 
ance carrier, is in their opinion bad. They believe 
it deprives the patient of any incentive to use the 
service with economy; it results in the doctor always 
being paid an average fee for his services unrelated 
to his seniority, experience, or skill; and it can pro- 
mote excessive demand by the patient or "overservic- 
ing" by the doctor. Though direct payment of the 
doctor by the insurer (or by Government) is con- 
venient, it leaves the patient "unaware of the cost 
of his medical services, and fails to educate him 
to his responsibility towards the doctor's time and 
the financial stability of the plan". 

The Canadians themselves have had experience 
in some provinces of schemes wherein the whole 



cost of medical care is paid by an insuring agency, 
and it is interesting to find them postulating that 
the totality of reimbursement, rather than the nature 
of the body providing it, is what leads to a wasteful 
misuse of resources. 

So the committee hold that any Government as- 
sistance to major sections of the population should 
be conditional on the patient (unless he is indigent) 
having an appreciable financial commitment in each 
item of service they divide the community into 
three groups — the self-supporting, the indigent, and 
the marginal. The self-supporting are defined as 
those who pay income-tax; the indigent are those 
so badly off as to need State assistance with clothing, 
housing, and food; and the marginal lies between 
these two extremes. Modelled on Australian prac- 
tice, a scheme has been devised which deals differ- 
ently with each of these groups. Self-supporting peo- 
ple would be required to insure for medical services: 
when these were received, 60% of the cost would 
be paid by the insurer, 20% would come from a 
Government subsidy, and they themselves would pay 
the remaining 20%. For the indigent, who would be 
uninsured, the government would pay 80% of 
the standard fees, and the profession would forego 
the other 20%. The marginal group would be pay- 
ing reduced insurance premiums, and for them the 
insurer would pay 20% of the charges, and the 
Government 60% ; the patient would still be liable 
for 20% — but whether this was asked for would be 
left for the doctor to decide. 

Many Canadians who at present have contracts 
with insurers for the payment of the full cost of 
medical expenses might be reluctant to substitute 
an arrangement which would give them only partial 
payment. But the report points out that the existing 
schemes for "total reimbursement" reimburse only 
the doctor's own fees, and, though they may meet 
standard charges for hospital care, they do not cover 
the cost of drugs or of prostheses, nor those of spe- 
cial nursing, physiotherapy, or ambulance transport. 
If all these extra benefits were included in the new 
package, the present policy-holders might be per- 
suaded to accept it. 

As the Canadian Medical Association Journal 
says, "the Canadian Medical Association is now 
called upon to relate its philosophical studies and its 
attitudes toward the practical realities of a series 
of recommendations which may have far reaching 
implications for medical practice in Canada". — The 
Lancet, London, December 26, 1964. 

References 

1. Canad Med Ass J. 1964, 91, No. 12. 

2. See Lancet, !963, i, 876. 



12 



U.S. NAVY MEDICAL NEWS LETTER 



DENTAL SECTION 



CARIES PREVALENCE WITH HIGH AND 
LOW INTAKE OF FLUORIDATED WATER 

Gray, A. S., Bonham, G. H., and Luttrell, M., 

390 Queensway, Kelowna, British Columbia, 

Canada. J. Canada D A 30. 550-555, Sept 1964. 

Some children may not necessarily receive an ade- 
quate supply of fluoride even when the community 
water supply is fluoridated, because they don't drink 
enough water. There are great differences in intake 
of fluoridated fluids by children in different homes 
in the same community. For instance, powdered 
milk when reconstituted with fluoridated tap water 
contains a significant amount of fluoride, whereas 
whole milk has no fluoride. 

Fluid-intake information was estimated retroac- 
tively (through interviews with parents and by esti- 
mates) for 160 six-year-old children in Prince 
George, British Columbia. 

The estimated average fluid and fluoride intakes 
in fluids of young children of this northern commu- 
nity probably are lower and more variable than those 
reported from other, warmer centers. 

For these six-year-old children during the winter 
months between October and February, the major 
sources of dietary liquids were milk, water and 
canned or frozen fruit juices. All 160 children drank 
milk, which formed 52.7 percent of the total fluid 
consumed. Consumption of milk averaged 17.6 oz. 
per day but the range was from 3 oz. to 52 oz. 
Only 136 children (85 percent) drank water as 
such; this was estimated as 23.8 percent of the total 
fluid consumed. The range of reported use of water 
was from 0.0 to 29 oz. per day, the average being 
7.9 oz. About 53 percent of the children reported 
drinking juices, which formed 7.8 percent of the 
total fluid consumed. 

The range of total fluid intake of these six-year- 
old boys and girls during the winter months was 
great — from 0.24 oz. per pound of body weight per 
day to 2.01 oz. 

Overall, a 52 percent reduction in DMF rates of 
Prince George children, 6 to 8 years old, was ob- 
served after six years of fluoridation. Perhaps an 



even greater reduction in caries attack rates might 
have resulted if the parents had encouraged children 
to drink water so that, by age six, each child would 
consume two full glasses per day throughout the 
year. 

EFFECT OF FLUORIDE DENTIFRICES ON 
TOOTH ENAMEL SOLUBILITY 

Giltings, B.R.D., Broadhurst, G. G., and Martin, 

N.D. University of Sydney, Sydney, Australia. 

Austral D J 9: 414^18 Oct 1964. 

Nonfluoride dentifrices have no effect on the in- 
vitro solubility of powdered bovine tooth enamel. 
Dentifrices containing fluoride reduce the solubility 
of the powdered bovine tooth enamel in pH 4.0 
acetate buffer solutions. Reduction in solubility of 
the tooth enamel was significant but not as great 
as that produced by the equivalent concentrations 
of sodium fluoride or stannous fluoride in aqueous 
solution. 

Treatment of enamel powder with 0.09 percent 
fluoride as an 0.2 percent aqueous sodium fluoride 
solution (the concentration claimed for the sodium 
fluoride dentifrice tested) reduced enamel solubility 
more than did the same concentration present in 
a dentifrice. Treatment of enamel powder with 0.09 
percent fluoride as an 0.4 percent aqueous stannous 
fluoride solution (the concentration claimed for the 
stannous fluoride dentifrices tested) also reduced en- 
amel solubility more than did the same concentration 
present in a dentifrice; the reduction was greater 
than that produced by the equivalent sodium fluoride 
solution. 

The improved performance of the stannous fluo- 
ride solution probably is due to the stannous ion. 

Yearling bovine lower incisors were collected, 
cleaned and sectioned, and the enamel was harvested 
and crushed. The powder was washed, dried and 
irradiated. The amount of enamel dissolved by the 
buffer solutions at each time interval (10, 20, 30, 
40, 50, and 60 minutes) could be determined by 
comparing the count rate of the sample with the 
count rate of the standard enamel sample prepared 
at the beginning of the experiment. In control ex- 



U.S. NAVY MEDICAL NEWS LETTER 



13 



periments, duplicate runs were made with no denti- 
frice treatment at all and with distilled water. Al- 
though this in vitro test is not a substitute for in vivo 
testing of dentifrices, the method is useful for 
large-scale screening of experimental dentifrice 
formulas. 

UNSUPERVISED CLINICAL TRIAL OF 
STANNOUS FLUORIDE DENTIFRICE 

Slack, G. L., and Martin, W, J. The London Hospit- 
al Medical College Dental School, London, England. 
Brit D J 117: 275-280, Oct 6, 1964, 
A two-year, double-blind clinical trial in 719 Brit- 
ish children aged 11 to 13 years old showed no 
difference whatsoever in the control of caries in the 
experimental group using a dentifrice containing 
stannous fluoride and a control group using a popu- 
lar dentifrice of standard composition containing 
no particular agent of proven value in controlling 
caries. The findings are at variance with most re- 
ports published on the efficacy of stannous fluoride 
dentifrices. 

The experimental dentifrice contained 0.4 percent 
stannous fluoride in a compatible base containing 
metaphosphate, glycerine, binding agents, sodium 
lauryl sulfate, flavoring, blue color and water. The 
control dentifrice contained dicalcium phosphate, 
glycerine, a binding agent, sodium, lauryl sulfate, fla- 
voring, blue color and water. The age of each denti- 
frice was between 8 and 12 weeks, to ensure compa- 
tibility with shop purchase. A constant and adequate 
supply of dentifrice and brushes for the whole family 
was maintained. 

The children were shown the film "Let's keep our 
teeth," and were told that their teeth should be 
cleaned at least three times per day — after breakfast, 
after lunch, and last thing at night. 

In 1961 a preliminary base line examination was 
made and both groups received the control denti- 
frice. In 1962 further base line examinations were 
made, and the stannous fluoride dentifrice was issued 
to the experimental group. Dental examinations were 
made in 1963 and 1964. The identity of the test 
group was not disclosed until the two years' results 
had been analyzed. 

The percentage of carious teeth at each examina- 
tion was essentially the same. There were no differ- 
ences between the two groups as to oral hygiene 
status and gingival condition. More black-brown 
stains were found on the teeth of subjects in the 
experimental group than in the control group. 

The failure to show any differences in caries status 
after the two-year trial is surprising when considered 



in the light of the published reports from the United 

States. 

IMAGE OF DENTISTS IN NEW MEXICO 

Benedetti, D. T., and Zip-pel, B. University of New 

Mexico, A Ibuquerque, New Mexico, Report of 

Survey. New Mexico D J 15(2) 160, IS August 
1964. 

In the view of the average, middle-aged New 
Mexico man with an annual income of about $8,000 
a year, the dentist is clearly a professional person 
with status below that of the physician and above 
that of the lawyer. The dentist is viewed as a person 
having a sedentary, relatively passive occupation 
whose services are extremely important but not 
indispensable. 

Of 500 questionnaires mailed to a random sample 
of New Mexico residents, 90 (18 percent) were 
returned. The middle and upper middle income 
homes were heavily represented in the sample. 

Asked for specific complaints, respondents were 
most concerned with fees charged by dentists and 
with the delay between the appointment and the vis- 
it. Only minor complaints were registered against 
"too many x-rays," pain or the use of local 
anesthetics. 

If dentists are interested in improving their al- 
ready good public image, they should think not so 
much in terms of altering specific practices as in 
terms of making their image more active and 
dynamic. 

EFFECTS OF CALCIUM— OR PHOSPHORUS 

—DEFICIENT DIETS ON SECONDARY 

CEMENTUM AND ALVEOLAR BONE 

OF RATS 

Ferguson, H.W., and Hurtles, R. L. School of 
Dental Surgery, University of Liverpool, Liver- 
pool, England. Arch Oral Biol 9:647-658, 
Nov. -Dec. 1964. 

Weanling rats were maintained for 14 weeks on 
diets low in calcium (0.026 percent) or low in phos- 
phorus (0.06 percent), with or without the addition 
of vitamin D. 

The formation of secondary cementum was dis- 
turbed most severely by a double deficiency of cal- 
cium and vitamin D. The disturbance caused by diets 
deficient in phosphorus and vitamin D, although se- 
rious, was not so severe. In contrast, a simple defi- 
ciency of phosphorus caused a greater disruption 
of cementum formation than did a simple lack of 
calcium. 

The observation that phosphorus deficiency per 



14 



U.S. NAVY MEDICAL NEWS LETTER 



se caused a greater metabolic disturbance in the for- 
mation of secondary cementum than did a simple 
deficiency of calcium is in accord with previous find- 
ings for bone and incisor dentin. 



In relation to a deficiency of phosphorus, cemen- 
tum reacts in a manner similar to bone; in relation 
to calcium deficiency, its behavior is more akin to 
that of the incisor dentin. 



PERSONNEL AND PROFESSIONAL NOTES 



Dental Officer Presentations. CAPT F. J. Kratochvil, 
DC, USN, U. S. Naval Dental School, Bethesda, 
Maryland, presented a series of four lectures enti- 
tled, "Planning Your Partial Denture;" "Mouth 
Preparation for Partial Dentures;" Designing Partial 
Dentures;" and "Partial Denture Occlusion and In- 
sertion," before the Ontario Dental Association, 
17-19 May 1965, in Toronto, Canada. CAPT Kra- 
tochvil will also present a lecture entitled, "Abuse 
and Recovery of Denture Supporting Tissues," be- 
fore the Massachusetts Institute of Technology 
Department of Nutrition and Food Science, on 2 
July 1965, in Cambridge, Massachusetts. 

CAPT A. L. Raphael, DC, USN, U.S. Naval Sta- 
tion, Charleston, S. C. served as guest speaker before 
the annual Special Navy Meeting of the Jacksonville, 
Fla., Dental Society, on 17 March 1965. CAPT Ra- 
phael spoke on the subject of Periodontia for the 
General Practitioner. 

CDR H. S. Samuels, DC, USN, U.S. Naval Hospi- 
tal, Pensacola, Fla., presented an illustrated essay 
entitled, "Oral Manifestations of Systemic Disease," 
before the Meridian Area Dental Society, on 20 
April 1965, in Meridian, Mississippi. 

CAPT G. W, Ferguson, DC, USN, Dental Officer, 
U.S. Naval Station, Newport, Rhode Island, present- 
ed a paper entitled, "Operative Dentistry — Its Many 
Facets," before the Twenty-first Annual Post-Col- 
lege Assembly, College of Dentistry, Ohio State 
University, on 14 April 1965, in Columbus, Ohio. 
CAPT Ferguson also presented a paper entitled, 



"Preventive — Operative Dentistry," before the 101st 
Annual Session of the Massachusetts Dental Society, 
on 5 May 1965, in Boston, Massachusetts. 

The following dental officers of the U.S. Naval 
Station, Newport, Rhode Island, presented lectures 
as indicated before the Newport County Dental So- 
ciety, on 26 April 1965. They also presented the 
same lectures before the Providence Dental Society, 
on 27 April 1965. CAPT A. E. Smith, DC, USN 
and LT A. S. Mowery, Jr., DC, USNR, "The Utili- 
zation of Endodontics and Crown and Bridge Proce- 
dures in the Restoration of Mutilated Teeth." LT 
L. L. Lancaster, DC, USNR, "The Oral Antral Fis- 
tula — Surgical Treatment." LT J. F. Begg, DC, 
USNR and LT M. G. Mowad, DC, USNR, "The 
Importance of Operative Procedures in Periodontics 
Patients." 

HEALTH TEACHING 

Oral Health 55(4): 55, April 1965. 

Health teaching to be effective must be simple. 
It must be at the level of the person's understanding 
and developed from the stage at which you find him, 
not at the stage at which you, the educator, think 
he should be. If this can be remembered, health 
teaching is not difficult. The following Chinese apho- 
rism can be accepted as a fundamental: 
If I hear it I forget, 
If I see it I remember, 
If I do it I know. 



PREVENTIVE MEDICINE 



INSECT VECTOR COLLECTION, ETHIOPIA, 
1961 

CDR L. W. Teller, Jr. MSC USN, 344450/ 
2300, Officer in Charge, Disease Vector Con- 
trol Center, Naval Air Station, Jacksonville, 
Florida. 

One of the attractive aspects of active duty in 
the Navy is the opportunity to "see the world." 



Sometimes shipboard duty assignments carry men to 
foreign ports, but interior visits are less com- 
mon. One of these latter instances occurred in 1961 
when CAPT Sidney A. Britten, MC USN, then the 
Officer in Charge of Preventive Medicine Unit No. 
7, Naples, Italy, received dispatch orders to proceed 
to Ethiopia to supervise the administration of 
100,000 doses of yellow fever vaccine. The author 



U.S. NAVY MEDICAL NEWS LETTER 



15 



was ordered to accompany the Navy group and to 
collect mosquito specimens in the epidemic area. 

The World Health Organization planned for the 
American group to inoculate villagers in a broad 
crescent ahead of the expected spread of the epide- 
mic. The area was generally in the southwestern 
quarter of Ethiopia. During April and May 1961 
insect vectors of yellow fever were difficult to find 
in most of the villages where inoculations were ad- 
ministered. In fact, the Savannah Country, at 6500 — 
9000 feet elevation, had relatively few places 
where mosquitoes could breed. After diligent search- 
ing, mosquito larvae were finally collected from 
springs, road puddles, artificial containers, tree holes, 
and from a fresh water lake. 

Several factors prevented our entry into the ill- 
defined epidemic area in the Omo River Basin. 
When it became apparent that visits were not pos- 
sible there, it seemed advisable to collect any and 
all insects available around villages scheduled for 
vaccine administration. At that time few Americans 
had been in the area described. A Prototype Vector 
Survey Kit (FSN 6545-982-4121) was utilized in 

DIPTERA 
CULICIDAE 

* Aedes aegypti 

A. circumluteolus 
A. cumminsi 
A. dentatus 
A. hirsutus 

* A. simpsoni 

Aedes (Mucidus) spp. 
A nopheles christyi 
A. gambiae 
Culex pipiens 
C. theileri 
C. tigripes 
C. trifilatus 
C. univittatus 
Culex (Culex) sp. 
Culex sp. (Misc.) 
Mansonia Fuscopennata 
M. Microannulata 

TICKS AND MITES 

Amblyomma coherens 
Amblyomma Sp. 
Haemaphysalis 1 . leachii 
* Yellow fever vectors 

The search for known vectors of yellow fever was 
not successful until the group was in a coffee grow- 
ing community within 50 miles of the "epidemic 



collecting, labelling and storing the specimens. Mos- 
quito larvae and ectoparasites were preserved in 
70% alcohol in small vials. The majority, however, 
were collected in chloroform -charged killing tubes. 
Whenever conditions permitted, a gasoline lantern 
was placed near a white tent to attract flying insects 
at night. 

There were over 400 specimens collected, repre- 
senting 1 1 insect orders, 39 families and 64 genera. 

The anopheles mosquitos were identified and 
retained by Mr. G. A. Verrone, formerly at the Ma- 
laria Eradication Service, Addis Ababa. 

The ticks were identified and retained by Mr. 
Makram N. Kaiser NAMRU #3, Cairo, U.A.R. 

The remaining specimens were sent to the Insect 
Identification and Parasite Introduction Research 
Branch, U.S. Department of Agriculture. Even 
though not all specimens have been identified 
enough have been processed to provide useful 
information. 

Arthropods of possible medical and veterinary im- 
portance are listed below: 

Rhipicephalus sp. near compositus 
Rhipicephalus s. simus 
Dermanyssidae (On Bat) genus & sp. ? 

MUSCIDAE 

Musca domestica 
M. sorbens 

Orthellia rhingiaejormis 
Stomoxys calcitrans 
S. niger 
S. varipes 
Fannia sp. 
Dichaetomyia sp. 
Muscina stabulans 

CALLIPHORIDAE 

Chrysomya chloropyga 

DIOPSIDAE 

Diopsis sp. 

SIPHONAPTERA 

PULICIDAE 

Pulex irritans 
Ctenocephalides canis 
Ct. felis 



area". Aedes aegypti and A. simpsoni were collected 
as they attempted to feed on the writer. 

Since livestock outnumbered the human popula- 



16 



U.S. NAVY MEDICAL NEWS LETTER 



tion, there were numerous dung-inhabiting flies 
from the family Muscidae. Musca sorbens was ex- 
tremely abundant and annoying, attempting to enter 
our nostrils, eyes, ears and mouth. The public health 
aspects of this situation require little imagination to 
see the vector potential. 

Of entomological interest were a number of work- 
ers of Megaponera foetens, a large stinging ant that 
emits a foul odor, the stalk-eyed fly, Diopsis, and 
the termites (Odontotermes) feeding on living euca- 
lyptus trees. Many Ethiopian huts used eucalyptus 
foliage to repel house-invading insects. 

In spite of the primitive conditions, the opportu- 
nity to visit Ethiopia was one of those which was 
professionally satisfying and long remembered. 

THE DECLINE OF PELLAGRA IN THE 
SOUTHERN UNITED STATES 

J.N. P. Davies, MD Brist, Professor of Pathology 
Albany Medical College, Albany, New York. The 
Lancet 2(7352):195-196, London, July 25, 1964. 

The first recorded outbreak of pellagra in south- 
ern United States was in 1907. By 1922, when regu- 
lar records were started, the disease was common 
and widespread throughout the county. Between 1930 
and 1933 the frequency of pellagra declined sharply, 
and today the condition is seen only in food faddists 
and alcoholics. The question is why a deficiency dis- 
ease, classically associated with ignorance, poverty, 
and malnutrition, should have declined most dramat- 
ically just when economic circumstances were at 
their worst? For in 1930 the United States was in 
the grip of the most severe economic, industrial, and 
agricultural depression it had ever known. 

KNOWLEDGE OF THE DISEASE 

The first national conference on pellagra was held 
at Columbia, South Carolina, in 1912 when the U.S. 
Public Health Service began investigating the disease. 
In 1915, pellagra was induced in convict volunteers 
fed a restricted diet; by 1922 the black-tongue 
syndrome had been similarly induced in dogs and 
cured by supplementing their diet with meat, milk, 
and yeast. Brewer's yeast in sufficient amounts was 
then found to cure human pellagra, and from 1928 
was provided, free of charge, by State and county 
health agencies and the American Red Cross. But 
the more potent liver extracts were not developed 
until 1932; and the pellagra-preventing factor, nico- 
tinic acid, was identified only in 1937. Thus there 
seems to be no direct connection between medical 
and biochemical advance and the sudden rapid de- 
cline of the disease in the South. 



ECONOMIC AND SOCIAL BACKGROUND 

The economy of the Southern States was based 
on cotton, and ever since the Civil War the South 
had been a more or less economically depressed 
area. When economic depression became general 
and cotton prices fell, farmers tended to increase 
the acreage under cotton so that higher sales would 
compensate for lower prices. In 1927 the southern 
farmer was worse off than he had been in 1922, 
and his net average income fell from about $874 
in 1929 to $342 in 1931. A tenant share-cropping 
system was general. Tenant farmers mortgaged their 
prospective crop yields and, if crops failed or prices 
fell, could not repay the loans. Wages were low and 
food prices high. Local stores could carry only a 
narrow range of provisions and merchandise. When- 
ever food prices rose pellagra became more 
widespread. 

Through proverty and force of habit, the populace 
comsumed a poor diet based on the three Ms — meal, 
meat, and molasses. The meal was a cornmeal, and 
the meat salt pork and lard. In better times these 
were supplemented by wheat meal, rice and dried 
beans. Very few people cultivated a garden. 

Before 1900 the corn was generally ground by 
small local water-driven mills which produced a 
coarsely bolted or unbolted meal retaining most of 
the germ and hull of the grain. As large milling 
concerns took over, this was replaced by a finely 
bolted meal which looked better, tasted better, and 
kept better than the coarser meal but lacked the 
germ and its vitamins. 

The pellagra situation deteriorated steadily in the 
1920s reaching its nadir in the years 1929-31. By 
1932-34 there had been great improvement: the 
number of cases reported from the southern States 
fell by 58%. The frequency of the disease remained 
at this lower level until, in the 1940s, pellagra vir- 
tually disappeared. Mortality reached a peak in 1930 
and has fallen ever since. Thus the decline of pel- 
lagra in the southern states began and was most 
rapid in the years 1930-33, the depths of the great 
depression. Since the development of pellagra takes 
time, the cause of this decline must have been in 
operation in 1930 or before. 

THE EXPLANATION 

There is much to suggest that pellagra began to 
disappear from the southern states because of a 
change in the eating habits of the populace. In 1916 
Goldberger and Wheeler (Pub Hlth Serv Hyg Lab 



U.S. NAVY MEDICAL NEWS LETTER 



17 



Bull 153: 85, 1929) carried out the dietary survey in 
a southern mill town; in 1932 Stiebeling and Munsell 
(US Dept Agri Techn Bull No. 352, 1932) repeating 
the survey, reported some notable changes. The in- 
take of lard, fat and lean meat, and cereals had 
altered little; sugar consumption had doubled as had 
the apparent consumption of potatoes and fresh and 
canned vegetables (the 1916 survey did not include 
home-produced vegetables) : eggs were more gener- 
ally used, the consumption of milk had gone up 
by V-i, and the number of families owning a cow 
had increased by 7 % . 

In 1927 Goldberger (Pub Hlth Rpt Wash, 42: 
2193, 1927) and Sydenstricker (Pub Hlth Rep 
Wash, 42: 2706, 1927) published reports on pel- 
lagra which clearly delineated the nature of the prob- 
lem and how it should be tackled. The Agricultural 
Extension Services were instrumental in transmitting 
this information to the rural agriculturalist. These 
had been established in 1902 with the aim of 
improving farming practice and generally raising 
rural standards of living. In the depression, when 
cotton became unsalable, it was the Extension Serv- 
ices which encouraged construction of cotton crops in 
the field and reduction of acreage; and it was their 
agents who persuaded the southern farmers to de- 
vote the land and labor thus liberated to the feeding 
of their own families. In the absence of any tempta- 
tion to concentrate on cash crops, the farmers were 
ready to listen to advice about the dietary prevention 
of pellagra. During the depression the number of 
small productive farms increased. The total arable 
acreage and production of principal crops (wheat, 
oats, barley, rye, flaxseed, corn, cotton, tame hay, 
potatoes, and sweet potatoes) fell sharply between 
1929 and 1933; but the production of soybeans, 
peanuts, field peas, citrus and other fruits, and eggs 
and cattle actually rose, and there is no doubt that 
the production of vegetables and farm products for 
home use increased enormously. In North Carolina, 
for example, where there were 88,800 home gardens 
in 1927, there were 113,655 in 1932. And it was 
this departure from cash-crop monoculture that led 
to the sudden decline in pellagra. 

CONCLUSION 

In many areas of the world today, hope of ever 
overcoming malnutrition seems dim. Poverty and ig- 
norance and intractable food habits are stubborn and 
hard to change; distribution of surplus farm products 
from other countries does nothing to improve the 
long-term prospects and may even depress local pro- 



duction. The southern States were poor and de- 
pressed, their soils eroded, and their people igno- 
rant. Yet, in the space of a few years, tenaciously 
held dietary habits were abandoned and the frequen- 
cy of deficiency disease was drastically reduced. The 
propaganda that achieved all this should repay closer 
study. 

MALARIA IMMUNOLOGY 

WHO Chronicle, 19(2): 82-83, February 1965. 

It has been known for a long time that acquired 
immunity to malaria does exist, notably in zones 
where the disease is endemic. The protective role 
of the serum gamma globulins of immune persons 
has been demonstrated experimentally. 

In the past, research on immunity to malaria was 
hampered by the ineffectiveness of the classic sero- 
logical techniques such as agglutination, precipitation, 
and to some extent complement fixation. New im- 
munological tools such as haemagglutination, Im- 
munoelectrophoresis, and immunofluorescence have 
proved more useful. 

In a recently published paper A. Vofler (Bull Wld 
Hlth Org, 30: 343, 1964) of the London School 
of Hygiene and Tropical Medicine, describes fluores- 
cent antibody methods and discusses their applica- 
tion in malaria. These methods of staining antibodies 
have shown that malaria parasites can be classed 
in several immunospecific groups according, for ex- 
ample, to whether they attack rodents, birds, or pri- 
mates. There are cross reactions between members 
of each of these groups, but not between members 
of different groups. It should be stressed that such 
serological cross reactions do not necessarily reflect 
functional cross immunity. 

Fluorescent antibody testing has made further 
progress possible in malaria serology. The author 
describes the methods used in such testing, which has 
the advantage of being rapid and specific; also, its 
results can be photographed. 

Immunofluorescent studies also indicate the exist- 
ence of antigenic resemblance between the sporo- 
zoites and the blood and exoerythrocytic stages of 
the malaria parasite. 

One of the most important applications of fluores- 
cent antibody methods has been in the detection 
and titration of malarial antibody. In human vol- 
unteers it has been observed that malarial antibody 
appears at the same time as the parasites in the peri- 
phereal blood. Subsequently, the level of antibody 
increases with the parasite rate and falls when the 
person is cured. 



18 



U.S. NAVY MEDICAL NEWS LETTER 



The same methods have been used for titration 
of antibody in an area where falciparum malaria 
is endemic. High antibody levels have been found 
in the serum of adults and in placental cord blood. 
Levels are low in children between 6 and 30 months. 
In older children they gradually increase. 

AIR POLLUTION 

WHO Mag. World Health, Page 17, Sept 1964. 

It is generally accepted that atmospheric pollution 
is a factor of importance in the causation of lung 
cancer in man. Epidemiological evidence points to 
a consistently increased incidence of lung cancer in 
urban as compared with rural areas that cannot be 
explained by differences in smoking habits. Physi- 
co-chemical analyses have demonstrated the pres- 
ence, in polluted air, of known carcinogens of the 
polycyclic aromatic hydrocarbon group (notably 3,4 
— benzpyrene), while other chemical types of car- 
cinogen and/or modifying factors are thought to be 
present. 

Preventive Measures 

1. Increased use of electricity and natural gas, 
to replace other domestic fuels. 

2. Development of more efficient domestic equip- 
ment for using coal and oil. 

3. Supplying heat to whole districts from central 
plants. 

4. Smokeless combustion of fuels in industrial 
furnaces through electrostatic precipitators, scrub- 
bers, etc. 

5. Elimination of smoke from diesel engines by 
careful control of operating conditions. It has some- 
times been suggested that diesel engine exhausts are 
more dangerous than gasoline engine exhausts. The 
evidence would suggest that the opposite is true. 

6. Development of exhaust control devices for 
automobiles. 

7. Improvements in the design of the internal 
combustion engine. 

8. Increased use of hydro-electric power. 

9. Increased use of electric and efficient diesel 
traction. 

10. Establishment of "green belts" between indus- 
trial and residential areas. 

SAFE HOLDING TEMPERATURES 
FOR COOKED FOODS 

It has been noted in various type-command publi- 
cations containing references to food-service prin- 



ciples that they are not in accord in stating safe 
holding temperatures for cooked foods as recom- 
mended by BUMED and contained in BUSANDA 
MANUAL, Volume III, para. 37776, Voume IV, 
para. 41741, and Volume VIII, para. 82611. The 
following information is presented for guidance and 
will be reflected in a forthcoming revision of Chapter 
1, "Food-Service Principles," of the Manual of Na- 
val Preventive Medicine. 

a. General. Protein foods which are not served 
immediately after cooking will be either chilled to 
temperatures of 40° F. or lower (but not frozen) 
or held at 140° F. or higher. Protein foods include 
meats, fish, poultry, gravies, meat stocks, soups, 
eggs, custards, cream fillings, and milk. Growth or 
harmful bacteria and the development of toxins 
(poisons) formed by the bacteria occur rapidly in 
cooked protein foods during holding at temperatures 
between 40° F. and 140° F. Cooked protein foods 
which have been held at temperatures between 
40° F. and 140° F. for more than 3 hours will 
be considered unsafe for consumption and will be 
destroyed. If the product is refrigerated at intervals 
and then permitted to warm up, the total time of 
the various periods between 40° F. and 140° F. 
will be not more than 3 hours. Protein foods that 
are composed of ingredients which are hand-peeled, 
hand-sliced, or hand-diced after cooking will never 
be used as leftovers, the 3 hour limit between tem- 
peratures of 40° F. and 140° F. is usually taken 
in preparing, chilling, and serving the food. These 
foods include potato salad, chicken salad, macaroni 
salad, shrimp salad, egg salad, and similar items. 
Hand preparation not only increases the chance of 
contamination, but generally increases the length of 
time that these foods are held at room temperatures. 
It is also dangerous to return opened jars or bowls 
of mayonnaise and cooked salad dressing from salad 
bars to refrigerators for reuse at a later meal. Be- 
cause of the danger of miscalculation of total lapsed 
time that these salad dressings have been held at 
temperatures between 40° F. and 140° F., 
mayonnaise and cooked salad dressings will be 
placed on the salad bar a small quantity at a time 
and will not be returned from the salad bar for reuse 
as leftovers. 

b. Leftovers to be Chilled. When leftovers or 
warm foods are chilled, care will be faken to assure 
prompt and thorough chilling (40° F. or below) 
to the center of the food mass. Foods that are to 
be refrigerated will be placed in shallow pans to 
a depth of not more than 3 inches and will be cov- 



U.S. NAVY MEDICAL NEWS LETTER 



19 



ered with lids or waxed paper. Such foods will not 
be put in large deep pans, as chilling may take so 
long to get to the center of the food mass that suffi- 
cient time is allowed for growth of harmful bacteria 
and the development of a toxin. Any other proce- 
dure which might delay cooling also will be guarded 
against. Food to be chilled will be placed in the chill 
box immediately. Leftover food will not be saved 
for more than 36 hours. Freezing leftovers is 
prohibited. 

c. Special Meals. The 3-hour maximum time per- 
mitted for holding cooked protein foods at tempera- 
tures between 40° F. and 140° F. is of particular 
importance in the case of special meals (boat meals 
and flight meals). It is essential that in preparing 
and using sandwich fillings (those containing meat, 
meat food products, poultry, fish, and eggs) that 
close galley supervision and liaison with using units 
be maintained to insure continuous refrigeration. 
Such fillings must not be held for more than 3 hours 
between temperatures of 40° F. and 140° F. (to- 
tal lapsed time in the galley and aboard aircraft or 
boats). Unopened cans of canned meat, chicken, 
and tuna will be issued in lieu of meat sandwiches 
when consumption is not anticipated within the 3- 
hour time limit between 40° F. and 140° F.; in 
these instances bread and butter sandwiches can be 
issued and consumed with the canned meat or poul- 
try. Members of the using unit may desire to add 
the canned meat to the bread and butter sandwich 
immediately prior to consumption. 
— Sanitation Section, PrevMed Div, BUMED, 

WARNING AGAINST REFRIGERATORS 

On 21 August 1964, the U.S. Public Health Serv- 
ice warned the public to be especially alert to the 
hazard of idle and abandoned refrigerators and ice 
boxes. 

In August 1964, there were 13 children killed 
by suffoctation in unattended, temporarily idle, or 
abandoned refrigerators in Maryland, Illinois, and 
California. Three children were found dead in an 
unused back porch refrigerator in Chicago, 3 were 
in an idle refrigerator in Baltimore, and 3 were in 
a freezer temporarily out of service in Los Angeles. 

Parents should be aware that an empty and idle 
refrigerator is a menace to the life of a child unless 
special action is taken to prevent entry or guarantee 
ventilation. Most refrigerator entrapment accidents 
occur to children under 6. If a refrigerator is to 
be junked, discarded, or abandoned, the doors 



should be removed or the appliance should be carted 
away and destroyed. 

The refrigerator temporarily out of use also is 
a death trap. It is recommended that upright units 
be placed so that the door stands against the wall. 
An added precaution to make the box "child proof" 
would be to encircle the box with strong filament 
tape or a simple chain secured with a padlock. Some 
owners may prefer to attach with plastic cement 
a small wooden block which will prevent complete 
closure of the door and insure a fresh air supply 
inside the box. The block can be removed when 
the appliance is to be restored to service. 

In recent years, the federal government and many 
municipalities and states have enacted laws designed 
to prevent entrapment within refrigerators. No 
deaths have been reported involving a refrigerator 
manufactured since 1958. The Public Health Service 
Division of Accident Prevention, which works close- 
ly with state and local health and medical officials 
and industry and trade association groups on this 
problem, has in production educational manuals ex- 
plaining to individuals and program planners how 
to prevent refrigeratory entrapment. 
— PHS DHEW, Press Release, August 21, 1964. 

INSECT SURVEY 
USS DENNIS J. BUCKLEY (DDR-808) 

An insect survey was conducted aboard the USS 
Dennis J. Buckley (DDR-808) on 15 January 1965 
by three members of the Entomology Department of 
the U.S. Navy Preventive Medicine Unit No. 5, San 
Diego, California. Accompanying the team on this 
survey were the Medical Department Representative 
and the mess deck Master- At-Arms. 

Despite an intensive search for the signs and pres- 
ence of cockroaches and other pestiferous insects, 
none were observed. What was observed, was a high 
level of sanitation throughout the vessel, demonstrat- 
ing fully the basic tenet that good sanitation is the 
first step toward successful control and elimination 
of cockroaches. Handouts included recommenda- 
tions for pest control materials and equipment and 
information on kepone-peanut butter bait. 

All hands, particularly Nizamian, J. P. HM1, Med- 
ical Department Representative and Wieland, C. 
W. BN1, mess deck Master- At-Arms, are to be com- 
mended for a job well done. "It is indeed a rare 
pleasure to survey a vessel exhibiting such coopera- 
tion at all echelons," stated the Officer-in-Charge 
of the U. S. Navy Preventive Medicine Unit No. 
5. 
—PrevMed Div, BUMED. 



20 



U.S. NAVY MEDICAL NEWS LETTER 



RESERVE TRAINING FOR MEDICAL 
ENTOMOLOGISTS 

The Armed Forces Pest Control Board will spon- 
sor a reserve training course for medical entomolo- 
gists from 26 July through 6 Aug 1965. This will 
be the 6th annual course in military entomology and 
will be presented by the Training Branch, Commu- 
nicable Disease Center, U.S. Public Health Service, 
Department of Health, Education and Welfare in At- 
lanta, Georgia. 

This course, which is limited to a maximum of 
28 attendees, is designed to replace that formerly 
offered at the Naval Medical School, National Naval 
Medical Center, Bethesda, Md. 



It is believed that the new course will be of greater 
value to the Armed Forces and to the individual, 
placing emphasis on the epidemiology of vector- 
borne diseases, and presenting military entomology 
problems around the world. 

Reserve Medical Service Corps Officers desiring 
to attend this course should request a quota for at- 
tendance, via the Commandant of their naval dis- 
trict, to the Executive Secretary, Armed Forces Pest 
Control Board, Forest Glen Section, WRAMC, Wash- 
ington, D. C. 20012. In view of the tri-service partic- 
ipation and limitation on attendance, requests for 
quotas should be forwarded as soon as possible. 
— PrevMed and Reserve Div, BUMED. 



KNOW YOUR WORLD 



DID YOU KNOW: 



That effective 27 July 1964, the Federal Commit- 
tee on Pest Control was established by joint action 
of the Secretaries of Agriculture, Interior, Defense, 
and DHEW, to replace the former Pest Control Re- 
view Board (FPCRB)? The functions of the new 
Committee have been broadened to continue the re- 
view of Federal pest control programs and to include 
the responsibility for reviewing and coordinating all 
Federal pesticide monitoring programs, public infor- 
mation programs relating to pest control, and re- 
search programs on pesticides and pest control. The 
Committee will function in part through subcommit- 
tees. It has already established the Pesticide Moni- 
toring Subcommittee and the Information Subcom- 
mittee, is in the process of establishing the Research 
Subcommittee, and has under consideration the for- 
mation of a fourth that will provide a forum for 
the exchange of scientific information among scien- 
tists and pest control program operators. ( 1 ) 



That in an effort to reduce infestation in flour, 
NSC Oakland, on behalf of DSSC, has been testing 
6 types of flour sacks under different storage condi- 
tions to determine which type of flour sack closure 
is best for repelling insects? Five AFs bound for 
WESTPAC will load 100 sacks of each type and 
carry them in their holds until they return. Upon 
the return of each AF from WESTPAC, the flour 
will be tested for insect infestation. (2) 



That in 1963, Coronary heart disease accounted 
for about 212,000 deaths among females in the 
United States, exceeding by more than 60% the toll 
from cancer? Arteriosclerotic heart disease is re- 



sponsible for Va of the total mortality among females 
and for nearly 3 /4s of their mortality from all types 
of heart disease combined. ( 3 ) 



That pulmonary paragonimiasis has been detected 
in Eastern Nigeria? C. Nwokolo reports (J Trop 
Med Hyg 67: 1, Jan 1964) the finding of pulmonary 
paragonimiasis in 4 patients who had never been 
outside Nigeria. These cases strongly suggest that 
endemic foci of the disease probably exist in scat- 
tered areas in Nigeria. The alternative mammalian 
hosts of the parasite, including cats and dogs, as well 
as the appropriate intermediate hosts (snails, crabs, 
and crayfish), abound in various parts of Nigeria. 
(4) 



That the National Tuberculosis Association, in a 
background statement on emphysema says the dis- 
ease was the primary cause of death stated on 
12,350 death certificates in 1962 throughout the 
United States, contrasted with 1,914 deaths from 
emphysema in 1952, "better than a six-fold increase 
(in the reported deaths) in 1 decade." (5) 



That in 1951 there were 500,000 reported cases 
of smallpox in the world? In 1963, 5 years after 
WHO had launched the worldwide smallpox eradica- 
tion campaign, there were less than 100,000. Of 
these, about 80% were in Asia. Prospects -of eradi- 
cating smallpox from the world has been stated by 
the WHO Expert Committee on Smallpox as 
follows : 

"The global eradication of smallpox is well within 
the bounds of possibility. The only reservoir is man; 



U.S. NAVY MEDICAL NEWS LETTER 



21 



infection is manifest; carriers do not exist, and suc- 
cessful vaccination provides effective immunity. Its 
eradication is a matter of concern to all countries, 
as those now free constantly run the risk of the intro- 
duction of the infection from endemic areas." (6) 

That in 1820 one American farmer produced 
enough food, fiber and other products for 4 people? 



In 1963 he supplied enough for 31 people, 5 of 
them in countries that import American foods. 

References 

1. Vector Control Briefs, Issue No. 14, P. 13, Feb 1965. 

2. Newsletter, U.S. Naval Supply Corps, XXVIII (2): 36, Feb 1965. 

3. Statistical Bull Metropolitan Life Insurance Co., 46: 5, Jan 1965. 

4. JAMA 188(3): 339, April 20, 1964. 

5. Medical Bull of Tobacco, 111(1): 4, Winter 1964-5. 

6. WHO Press Release SEAR 783, April 4, 1965. 



DEPARTMENT OF THE NAVY 

U. S. NAVAL MEDICAL SCHOOL 

NATIONAL NAVAL MEDICAL CENTER 

BETHESDA, MARYLAND 20014 



POSTAGE AND FEES PAID 
NAVY DEPARTMENT 



OFFICIAL BUSINESS 



PERMIT NO. 1048 



22 



U.S. NAVY MEDICAL NEWS LETTER